Restrictions on receiving benefits for temporary incapacity for work

The Estonian Health Insurance Fund is legally obligated to ensure the efficient use of its budget (clause 1 of subsection 2 of § 2 of the Estonian Health Insurance Fund Act).

The Estonian Health Insurance Fund has the legal right to refuse payment of the benefit if there are no valid grounds for it and to recover the unfounded benefit from the insured person or withhold it from future benefits.

The Estonian Health Insurance Fund pays the benefit for temporary incapacity for work based on the submitted certificate of incapacity for work.

If the certificate includes information that precludes the payment of benefits, the Estonian Health Insurance Fund will refuse to make the payment.

If corrections to the certificate are submitted to the Estonian Health Insurance Fund after the benefit has already been paid, and a recalculation reveals that the person received the benefit unjustifiably, the Estonian Health Insurance Fund may recover the unfounded benefit from the person or withhold it from subsequent payments.

Common cases leading to the non-payment or reclaiming of the benefit:

• Incorrectly recorded period of incapacity for work. The health care professional (e.g., family physician, family nurse) corrected the sick leave to a shorter duration.  
• The person did not actually require the certificate of incapacity for work.
• The certificate of incapacity for work was issued to the wrong person.
• The person was working during the period of incapacity for work. The person loses the right to receive the temporary incapacity benefit as of the date on which they start working or doing business.
• The person receives income subject to social tax (e.g., wages) for the period of temporary incapacity for work.
• If the person is on vacation during the period of incapacity for work, they are not entitled to receive the benefit for the duration of the vacation.  

It is important to note that the exemption from work during the period of a certificate of incapacity for work applies to all workplaces of the insured person. This means that if a certificate of incapacity for work has been issued, the person must not perform work duties, receive wages for the period covered by the certificate, or be on vacation at any workplace in order to be eligible for the temporary incapacity benefit.

Repayment of overpaid benefit

If you have received a benefit to which you were not entitled, it must be repaid.

The Estonian Health Insurance Fund will send you a letter explaining the situation before making an administrative decision (precept). You may submit your opinions or objections within the time frame specified in the letter.

An unjustifiably received benefit can be returned through offsetting (the Estonian Health Insurance Fund will deduct the overpaid amount from future benefits). If offsetting is not possible, the benefit can be repaid either as a lump sum or in installments (by agreement).

If the person has received a repayment precept but does not fulfill it by the deadline, the Estonian Health Insurance Fund has the right to forward it to the bailiff for enforcement. In this case, the person will also be required to pay the costs of the enforcement procedure.